Provider Demographics
NPI:1578549333
Name:GILLIAM, MARTHA JANE (ANP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:JANE
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:JANE
Other - Last Name:SIMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP-BC
Mailing Address - Street 1:PO BOX 31235
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85751-1235
Mailing Address - Country:US
Mailing Address - Phone:520-324-4100
Mailing Address - Fax:
Practice Address - Street 1:5301 E GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2805
Practice Address - Country:US
Practice Address - Phone:520-324-3771
Practice Address - Fax:520-324-8091
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN053744163W00000X, 363LA2200X
AZAP0273363LA2200X
AZAP7115363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ574576Medicaid
AZP32968Medicare UPIN